HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 167 DUNCAN DRIVE 7/1/2026 Commonwealth of Massachusetts Town of Nmh Andover
C6 2026 ity/Town of JUL -
System Pumping Record
y Form 4 Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
-HOUSE:---n:f�ro!n lback side rear le'(right""",
A. Facility Information BUILDING: front back side rear left C-
Important:When DECK: under
f Ming out forms 1. System Loca
on the computer,
use only the tab
key to move your Ad
r4
cursor-do not MA
use the return
key, City[Town State Zip Code
2. System Owner,
Name
Address(if different from location)
MA
City/Town State Zip Code
-telephone Umt
Nur
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: E] Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
0 Other (describe):
4, Effluent Tee Filter present? D Yes EEj-'Nb If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6, ystem Pumped By:
(_jp,a�Le T I n e Mass 1AA95E (Mass 1AD31Z
Name Vehicle License Numbe�"---
'Enterprises,
_Bateson Ent _I.nc.
eoMpany
L
Location wh r contents were disposed:
GLSD
Signature of Hauler Date
Sig
nature
of Receiving
ng Facility
or attach
facility
.receipt) Date
t5form4.cloc- 11112 System Pumping Record-Page 1 of 1